Workers compensation treatment guidelines can help prevent unnecessary medical procedures and the prescribing of potentially harmful medications. However, they are not all the same, nor are they without challenges. Understanding a jurisdiction’s strengths/weaknesses, taking a strategic approach to developing guidelines, and using common sense can lead to better outcomes for injured workers—and, ultimately, lower costs for payers.

That’s the view of workers compensation experts who spoke during our Out Front Ideas with Kimberley and Mark webinar, “Obstacles and Opportunities of Treatment Guidelines.” The panel included the following representatives from the regulatory, medical, pharmacy benefit management, and third-party administrator communities.

Texas Transition Success

Texas is a state that had some of the highest workers compensation costs in the nation, along with some of the poorest return-to-work and patient satisfaction outcomes. After implementing treatment guidelines and a drug formulary, the state now boasts some of the best workers compensation outcomes in the nation as well as lower costs. It would be 2 years for the treatment guidelines to be implemented and 3 years after that for the drug formulary to begin being phased in—first with new claims, then with legacy claims.

Evidence-Based Medicine: Texas switched to basing the guidelines on evidence-based medicine (EBM) to reform the previous consensus-based model, which was perceived as allowing for too much unnecessary medical care. EBM was chosen as the standard for selecting treatment guidelines, return-to-work guidelines, and adjudicating claim level disputes on medical care. It is also the standard expected from healthcare providers, payers, and others.

The idea of EBM is to provide a systematic approach to treating injured workers based on the best available science. Ideally, medical providers should base their treatment regimens on EBM, although it is also important to consider the specific needs of each individual patient.

Challenges of Developing Workers Compensation Treatment Guidelines

A claims examiner may not see a recommended treatment in the guidelines for a particular jurisdiction and issue a denial for a requested procedure. But, upon further investigation, the treatment requested by the provider may be the best for all considered.

Flexibility: In a California case, a claim was halted for several years—with indemnity expenses continuing to be paid—as the parties awaited the outcome of a dispute over an MRI scan. The case points to the need for those involved in a claim to be flexible. While following the guidelines should be the general rule of thumb, it’s also important that those overseeing a claim take a holistic approach and see what really makes sense for the injured worker.

Keeping current: Keeping the guidelines current is another challenge for some jurisdictions. With medical science changing rapidly, it’s best if jurisdictions and a way to get updated information published as soon as possible and make it easily accessible.

“Out Front Ideas with Kimberly and Mark” is a complimentary webinar series and interactive forum designed to explore critical workers’ compensation-related issues that are not given enough attention in other industry outlets. Hosted by Kimberly George and Mark Walls, two well-known experts and advocates in their fields, this series will explore the perspectives of risk managers, brokers, TPAs, carriers and other industry stakeholders in a conversational format.

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